Laser retinopexy is an established method of prophylaxis against retinal detachments. The goal of treatment is to create a chorioretinal scar surrounding a retinal break in order to both counter the effect of vitreoretinal traction on the tear and obviate liquefied vitreous from entering the subretinal space to generate a retinal detachment. Current modalities of laser application include laser indirect ophthalmoscope (LIO), slit-lamp, and intraoperative endolaser. LIO has the benefits of dynamic patient positioning and the ability to treat anterior tears with scleral depression. It is especially useful for wheelchair-bound patients, those with intraocular gas bubbles, or in the operating room setting. However, with LIO there is notable variability in laser spot size, burn intensity, and delivery location as a result of the independent mobility of the operator, lens, and patient. Slit-lamp retinopexy may be a good choice for patients with mid-peripheral tears, concurrently offering contact-lens stabilization of the patient's eye. Although precision patterned slit-lamp retinopexy has been previously described using the Pascal laser (Topcon Medical Systems, Oakland, NJ), we present the first report in the literature describing the planned retinopexy of a retinal tear using a navigated laser system.
The navigated laser photocoagulator (Navilas; OD-OS, Teltow, Germany) is a novel slit-lamp-based retinal laser delivery system with integrated digital fundus imaging (live color fundus photographs, red-free and infrared imaging, and fluorescein angiography) that aligns preplanned computer-guided and digitally documented treatment maps with real-time fundus images for the purposes of precise laser application. The system uses a solid-state yellow diode laser (577 nm) and features fundus landmark registration and eye-tracking mechanisms to ensure precise delivery of predesigned laser plans. The Navilas has been utilized for the treatment of diabetic macular edema, proliferative diabetic retinopathy, retinal vein occlusion, central serous retinopathy, and choroidal neovascularization and has been reported to have excellent accuracy, decreased laser times, and improved pain scores.1–9 Additionally, the Navilas allows the user to digitally mark regions of the fundus that are off-limits to laser photocoagulation; this feature may obviate accidental laser application to the optic nerve or fovea.
In this report, an otherwise-healthy 54-year-old woman presented to our institution's comprehensive clinic with 2 days of flashes and floaters of her right eye. Her best-corrected visual acuity was 20/30, and her pressure was 13 mm Hg. Dilated fundus examination of the right eye showed a large horseshoe tear in the midperiphery at the 3-o'clock position (Figure 1).
Optos fundus photo of the right eye demonstrating a Weiss ring (left arrow) and a large horseshoe tear at the 3-o'clock position (right arrow).
After a discussion regarding the risks and benefits of treatment, the patient provided consent for laser retinopexy. A topical anesthetic agent was applied to the operative eye. An Ocular Mainster PRP 165 (Ocular Instruments, Bellevue, WA) was utilized as a viewing contact lens. The Navilas laser system was powered on, and a digital target overlay pattern was designed against fundus imaging. Pattern laser retinopexy was performed incorporating navigated rapid panretinal photocoagulation technology to produce a 3 × 3 square pattern surrounding the horseshoe tear (power, 340 mW; duration, 30 ms; spot size, 390 µm; spot spacing, 1 spot size; applications, 242 spots) (Figure 2). The entire procedure took fewer than 9 minutes to perform (Figure 3). The patient tolerated the procedure well and without complications. On follow-up, the horseshoe tear remained well-lasered and without evidence of subretinal fluid or detachment.
(Left) A planned digital target overlay pattern is designed prior to the procedure. (Right) Burn marks immediately after the laser is deployed.
Operating the Navilas laser: Interaction with the system occurs over a touch-screen display in a “heads-up” posture.
In this report, we describe the application of a navigation laser system for the laser retinopexy of a symptomatic retinal horseshoe tear in the midperipheral fundus. Advantages of the Navilas system include improved upright positioning for the patient and a more comfortable “heads-up” posture for the surgeon; the ability to plan and design treatment a priori; precision delivery of laser less dependent on operator and patient movement; fidelity in laser placement away from the optic nerve and fovea; and a rapid procedure time.3–9 Despite the widefield view, the Navilas may not be appropriate for anterior tears that require scleral depression. The risks of navigation laser systems are similar to those of any other laser retinopexy, including inadvertent laser to the macula, vitreous or choroidal hemorrhage, choroidal neovascularization, choroidal effusions, epiretinal membrane formation, or anterior segment laser burns. Further studies are needed to elucidate the long-term efficacy of navigation laser versus traditional slit lamp or LIO modalities for the treatment of retinal breaks.
- Alshahrani ST, Ghazi NG. Navigated laser (navilas) therapy for choroidal neovascular and hyperpermeability pathologies. Retin Cases Brief Rep. 2015;9(2):117–120. doi:10.1097/ICB.0000000000000107 [CrossRef]
- Chhablani J, Rani PK, Mathai A, Jalali S, Kozak I. Navigated focal laser photocoagulation for central serous chorioretinopathy. Clin Ophthalmol. 2014;8:1543–1547. doi:10.2147/OPTH.S67025 [CrossRef]
- Neubauer AS, Langer J, Liegl R, et al. Navigated macular laser decreases retreatment rate for diabetic macular edema: A comparison with conventional macular laser. Clin Ophthalmol. 2013;7:121–128.
- Jung JJ, Gallego-Pinazo1 R, Lleó-Pérez A, Huz JI, Barbazetto IA. Navilas laser system focal laser treatment for diabetic macular edema - one year results of a case series. Open Ophthalmol J. 2013;7:48–53. doi:10.2174/1874364101307010048 [CrossRef]
- Kulikov AN, Maltsev DS, Boiko EV. Navigated pattern laser system versus single-spot laser system for postoperative 360-degree laser retinopexy. J Ophthalmol. 2016;2016:9871976.
- Ober MD, Kernt M, Cortes MA, Kozak I. Time required for navigated macular laser photocoagulation treatment with the Navilas. Graefes Arch Clin Exp Ophthalmol. 2013;251(4):1049–1053. doi:10.1007/s00417-012-2119-0 [CrossRef]
- Kernt M, Cheuteu RE, Cserhati S, et al. Pain and accuracy of focal laser treatment for diabetic macular edema using a retinal navigated laser (Navilas). Clin Ophthalmol. 2012;6:289–296. doi:10.2147/OPTH.S27859 [CrossRef]
- Kozak I, Kim JS, Oster SF, Chhablani J, Freeman WR. Focal navigated laser photocoagulation in retinovascular disease: Clinical results in initial case series. Retina. 2012;32(5):930–935. doi:10.1097/IAE.0b013e318227ab5b [CrossRef]
- Kozak I, Oster SF, Cortes MA, et al. Clinical evaluation and treatment accuracy in diabetic macular edema using navigated laser photocoagulator Navilas. Ophthalmology. 2011;118(6):1119–1124. doi:10.1016/j.ophtha.2010.10.007 [CrossRef]